Let’s start with this: Bipolar disorder is quite difficult to diagnose accurately. Quite difficult. Establishing this diagnosis isn’t something to be decided upon on the first visit with a client, as this is utterly unrealistic. There are too many variables and moving parts linked to bipolar to establish diagnostic certainty early on.
Getting Started
Consider this the “warm-up” period, where you begin developing rapport, easing the client into the treatment process. Over the years I’ve settled on a couple of different approaches. The first is to simply allow the client to “tell their story.” Via this process, I’ll guide them with some initial questions such as, “are you primarily here for ongoing management, or consultation?” “What diagnosis have other clinicians discussed with you?” If they respond they’ve been previously diagnosed with bipolar, I’ll ask why to determine what circumstances lead the treating clinician to conclude that bipolar is the issue. Some clients will respond they were hospitalized or incurred serious consequences resulting from a manic episode, in which case I’ll inquire about that episode and ask more about that. But quite commonly, they’ll say, “well, someone diagnosed me as bipolar, but I don’t know why, and it wasn’t really explained to me.”
An alternative approach is to be as systematic as possible through the employment of diagnostic screening tools such as the Mood Disorder Questionnaire, Beck Depression Inventory and Beck Anxiety Inventory. Systematic approaches are widely accepted, but keep in mind they may be only snapshots in time, in that people’s responses may only reflect how they’re thinking or feeling at the time they’re filling out the questionnaire or inventory. Instead, consider trusting your own questioning, observational skills and instincts regarding the patient before you. Not everyone fits neatly into rating scale or pre-determined questioning formats.
Ask About Substance Abuse
Substance abuse of any kind complicates every aspect of diagnosis and treatment of any mental disorder, but particularly bipolar – with its potentially numerous ups and downs. Substance abuse mimics bipolar symptoms to the hilt and will absolutely influence a poor outcome. Try your best to determine the timing of these issues – which came first the substance abuse or mood disorder? But don’t wait to get a patient sober or drug-free before proceeding with evaluation and treatment of the mood disorder.
Next Step – Focus on Previous Depressive and Manic Episodes
Ask this question: “Have there been times in your life when you’ve felt so sad, down and withdrawn that you isolated yourself in such a way that people noticed your absence and commented on it?” Using this question as a starting point will help establish how many episodes the individual may have had, and how much time has been spent in depression. The longitudinal course is important in that it identifies mood patterns. After asking about depression, move on to mania with this question: “Have there been times when you can remember having considerable energy for getting things done, whereby you needed little sleep and felt really up in such a way that other people noticed and commented, and said they thought you were acting oddly or different?” If acknowledged, then probe a bit more and evaluate the extent to which the periods of mania markedly affected functioning (indicative of bipolar I) or whether the episodes were milder and more hypomanic in nature (indicative of bipolar II).
Next Up – Family History
“Is there anyone in your family, as far back as you can remember, who has been hospitalized or treated for what turned out to be bipolar disorder, or treated for ongoing odd behavior that involved marked and distinct mood swings?” Family history is very important, particularly with bipolar disorder, due to its high level of inheritability. Alternatively, if there is no evidence of psychiatric illness in a family, then that really does question a bipolar diagnosis.
Discussing Diagnosis
After having completed the evaluation and assessment steps discussed above, spend a few minutes educating the client about your diagnostic impressions. The goal here is to convey the importance of pursuing treatment. Psychoeducation helps enhance compliance and urgency to act upon treatment recommendations. Take a compassionately direct approach: “I believe you have bipolar disorder and here’s why I think so.” Then follow that with a positive, hopeful statement: “Your condition is certainly treatable, and if you work with me, I believe that together we can achieve a favorable outcome.” “Does that sound okay to you?”
Medication
Lithium remains the gold standard for acute mania and bipolar maintenance and that’s not going to change. Unfortunately, the drug’s use is often eschewed by primary care prescribers and even some psychiatrists because lithium carries the baggage of frequent blood level monitoring – at least at first – and potentially troublesome side effects, (hypothyroidism; kidney dysfunction). Lithium substantially decreases the risk of suicide in bipolar patients. Seroquel immediate release, as well as the XR formulation; Symbyax and Latuda are the best available options for bipolar depression.
When medication is employed in treating bipolar disorder, there can be a tendency among physicians and other prescribers to be entirely too reactive to sometimes even normal day-to-day- variations in a patient’s mood. Mood and feelings shift throughout the day even in healthy subjects. So, it’s imperative not to be overly reactive and pathologize mood changes by adding more medication for what may be no more than a 2 or 3-day mood “blip.” In other words, it’s unwise to chase symptoms with yet more drugs. Also be willing to acknowledge that if medication treatment is failing, the diagnosis may be wrong.
Attribution Statement:
Joe Wegmann is a licensed pharmacist & clinical social worker has presented psychopharmacology seminars to over 10,000 healthcare professionals in 46 states, and maintains an active psychotherapy practice specializing in the treatment of depression and anxiety. He is the author of Psychopharmacology: Straight Talk on Mental Health Medications, published by PESI, Inc.
To learn more about Joe’s programs, visit the Programs section of this website or contribute a question for Joe to answer in a future article: joe@thepharmatherapist.com.